Often times, claim rejections and negative outcomes from billing compliance audits are results of ineffective or nonexhaustive billing processes within the skilled nursing facility (SNF). The below information will help providers lay the foundation for a comprehensive billing system that safeguards against these pitfalls by highlighting one special consolidated billing (CB) case involving services that don’t fall squarely into included or excluded categories whose navigation could otherwise throw a wrench in workflows: Categorical service exclusions.

Ensuring SNF staff understand how to bill for categorical service exclusions that don’t fall squarely into one of the five major CB categories (such as certain ambulance trips and care involving professional input from outside providers), as well as unique billing methods and rules that come into play under exceptional circumstances (e.g., roster billing for certain vaccinations), is essential to collect the most reimbursement for the facility.

Categorical exclusions

In addition to the four major CB categories that revolve around exclusions, there are a number of additional services that are categorically excluded from SNF consolidated billing when rendered by outside providers to SNF residents during Part A stays:

Ambulance trips that convey a beneficiary to a SNF for initial admission or from the SNF following discharge

Physician services are defined by the Medicare Physician Fee Schedule (MPFS), including the professional component of diagnostic tests

Physician professional services as defined by the MPFS when furnished by authorized nonphysician practitioners (e.g., physician assistants working in collaboration with a physician, certified nurse midwives, qualified psychologists, certified registered nurse anesthetists, and clinical nurse specialists)

Services furnished by a rural health clinic or federally qualified health center that would meet all other necessary exclusion criteria

Because these services are reimbursed outside of SNFs’ prospective payment system (PPS) daily rate, they should be separately billed to Part B by the actual renderer.

Still have questions? Take a closer look at the five major categories of consolidated billing during our 90-minute webinar delivered by industry and billing expert Janet Potter, CPA, MAS, senior manager for Marcum, LLP, Wednesday, May 31, 1-2:30 p.m. ET. Sign up here!

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Complimentary Networking Event for Post-Acute Leaders

Our upcoming Post-Acute Forum takes place November 18 & 19, 2019 in Phoenix, AZ. This complimentary event is specifically designed for decision-makers at skilled nursing facilities and home health agencies.